Which endovenous ablation method does offer a better long-term technical success in the treatment of the incompetent great saphenous vein? Review.

OBJECTIVE: The aim of this review article was to evaluate the long-term technical success rates of the known endovenous ablation procedures in the treatment of the incompetence of the great saphenous vein. METHODS: A literature search was conducted in the PubMed-database until the 5 January 2016. All publications with four to five years follow-up were eligible. Meta-analysis was performed by the IVhet-model. RESULTS: Eight hundred and sixty-two unique publications were found; 17 of them were appropriate for meta-analysis. Overall, 1420 limbs were included in the trial, 939 for endovenous laser ablation, 353 for radiofrequency ablation and 128 for ultrasound guided foam sclerotherapy. Overall, technical success rates were 84.8% for endovenous laser ablation, 88.7% for radiofrequency ablation and 32.8% for ultrasound guided foam sclerotherapy. There were no significant differences between endovenous laser ablation, radiofrequency ablation and ultrasound guided foam sclerotherapy regarding the great saphenous vein reopening (p = 0.66; OR: 0.22; 95% of CI: 0.08-0.62 for radiofrequency ablation vs. endovenous laser ablation; p = 0.96; OR: 0.11; 95% of CI: 0.06-0.20 for endovenous laser ablation vs. ultrasound guided foam sclerotherapy; p = 0.93; OR: 3.20; 95% of CI: 0.54-18.90 for ultrasound guided foam sclerotherapy vs. radiofrequency ablation). CONCLUSION: Both endovenous laser ablation and radiofrequency ablation are efficient in great saphenous vein occlusion on the long term. Lacking long-conducted large trials, the efficacy and reliability of ultrasound guided foam sclerotherapy to treat great saphenous vein-reflux is not affirmed.

[Cryosclerosis. The forgotten endovenous cryoablation of the great saphenous vein. Mid-term results of a prospective comparative trial]. / Cryosclerosis. Az elfelejtett endovénás cryoablatio a vena saphena magna elégtelenségének kezelésében. Egy prospektív összehasonlító vizsgálat középtávú eredményei.

INTRODUCTION: Cryosclerosis was introduced by Milleret and Le Pivert in the 1980s. METHOD: A prospective non-randomized comparative study has been performed on initial 96 patients. 48 patients were treated by cryosclerosis and the others received conventional stripping. 52 cases were analyzed for 2-years. The primary end-point of the study was to determine the occlusion rate of cryosclerosis. The clinical failure, the improvement in the Clinical Etiologic Anatomic Pathophysiologic classification and Venous Clinical Severity Scores were analyzed as secondary outcome. RESULTS: Total recanalization of the great saphenous vein causing clinical failure was observed in one case (4%). The reopening of the great saphenous vein was observed in 4 limbs (15%) that did not cause the incompetence of the trunk. The occlusion rate was 81%. Recurrent varicosity was observed by 35% and 42% of the patients in the cryosclerosis and stripping groups respectively. There was no significant difference between the groups (log rank test, p = 0.391). There was significant improvement in both the Clinical Etiologic Anatomic Pathophysiologic classification and Venous Clinical Severity Scores in each group without remarkable differences observed between the groups either at baseline or on the mid-term. CONCLUSIONS: Cryosclerosis seems to be effective in the remodeling of the great saphenous vein. The method has no remarkable mid-term clinical advantages over classical stripping so far. Orv. Hetil., 2016, 157(50), 1994-2001.

[Pneumoperitoneum after jacuzzi bathing -- an unusual cause for the development of intraperitoneal free air]. / Jacuzzihasználatot követoen kialakult pneumoperitoneum, avagy a szabad hasi levego keletkezésének ritka esete.

Free air within the intraperitoneal cavity most frequently occurs in conjunction with perforation of a hollow viscus and requires urgent surgical intervention. However, approximately 10% of all cases of pneumoperitoneum may not be correlated with disruption of the gastroinestinal tract. In the literature this condition is termed "nonsurgical" (NS) pneumoperitoneum and usually requires conservative management. NS pneumoperitoneum can be classified into the following categories: abdominal, thoracic, gynecologic, and idiopathic. We present a rare case of NS pneumoperitoneum. A 61-year-old woman who underwent a hysterectomy previously is admitted with diffuse abdominal pain without any other symptoms. Chest and abdominal radiographs verified the presence of free air under the diaphragm. We performed an exploration but no evidence of perforated viscus or peritonitis was found. Finally the patient told us that her complaints developed during Jacuzzi usage. We thought therefore that air entered into the intraperitoneal cavity through the vagina by influence of high pressure douche. In the course of postoperative gynecological examination a vaginoperitoneal fistula was detected in the vault which is developed during Jacuzzi usage leading to NS pneumoperitoneum. Essentially, NS pneumoperitoneum usually occurs without signs and symptoms of peritonitis and requires conservative treatment. Detailed physical examination and medical history taking can help to avoid unnecessary surgery in spite of radiological evidence of intraperitoneal free air.

[Occult inguinal-hernia in athletes]. / Sportolók occult lágyéksérve.

INTRODUCTION: The occult inguinal hernia in athletes represents a distinct entity as well as a part of a syndrome known as PIPS (public inguinal pain syndrome). It may be relatively difficult to identify the possible source of inguinal pain, since the spectrum is so wide that it can overlap various medical subspecialties. PATIENTS AND METHODS: This study includes 14 cases of athletes (11 football players) with suspicion of occult inguinal hernia. All of them complained of suprapubic pain on physical activity which was relieved at rest. No hernia was found on physical examination in either patient. Ultrasonography of the region demonstrated protrusion of the posterior abdominal wall by increased intraabdominal pressure (such as coughing) in 12 cases. Diagnostic laparoscopy was performed in every case, and we found 13 medial and 1 femoral hernia, i.e. a hernia was identified in all patients. Laparoscopic hernia repair with TAPP (transabdominal preperitoneal) technique was carried out in every case. RESULTS: Patients were discharged 2-3 days after surgery without any postoperative complication. A gradual increase in physical activity was advised up to the limit of complaints commencing 7-10 days later. All patients could return to competitive sports after 4-6 weeks. CONCLUSION: Differential diagnosis of inguinal pain in athletes includes occult inguinal hernia, which can be diagnosed with laparoscopy and TAPP repair can be carried out at the same time, if needed, to fix it.

30 years' experience in the treatment of low-risk gestational trophoblastic neoplasia in Hungary.

OBJECTIVE: To review the clinical experience in the treatment of patients with low-risk gestational trophoblastic neoplasia (GTN) over the past 30 years in a national trophoblastic disease center. STUDY DESIGN: Between January 1, 1977, and December 31, 2007, 302 patients with low-risk GTN were treated. The patients were directed to our institution from all parts of Hungary. The patients were 14 to 53 years of age with an average age of 28.3 years. Methotrexate (MTX)/folinic acid or actinomycin-D (Act-D) primary chemotherapy was selected based upon the patient's stage and prognostic score of GTN. RESULTS: Among 218 low-risk patients, 210 (96.3%) achieved remission as a result of MTX therapy. In 8 patients (3.7%), MTX-Act-D-cyclophosphamide (MAC) combination chemotherapy was needed to achieve complete remission, in some cases assisted by operation. Among 84 patients, 81 (96.4%) achieved remission as a result of Act-D therapy. In 3 cases (3.6%) complete remission was achieved by MAC combination chemotherapy. We detected metastases in 22.8% (69/302) of our low-risk patients. Chemotherapy, surgical intervention or other supplementary treatments resulted in 100% remission in cases of low-risk nonmetastatic and metastatic disease. CONCLUSION: Our data indicate that MTX/folinic acid or Act-D should be the primary treatment in patients with nonmetastatic or metastatic low-risk GTN. Importantly, patients with resistance to single-agent chemotherapy regularly achieve complete remission with MAC combination chemotherapy. Results show that patient care under the direction of experienced clinicians serves to optimize the opportunity for cure and minimize morbidity.

[Repairs of inguinofemoral and ventral hernias--review]. / A lágyéktáji és hasfali sérvek laparoscopos mutétei - áttekintés.

In this article the author reviews the results, technology and latest achievements in the history of laparoscopic hernia repair. In conclusion, having considered the advantages and disadvantages, laparoscopic hernia repair offers the best results in terms of early rehabilitation, early and long-term postoperative pain and a very low recurrence rate (less than 1% and 5%). In the hands of experienced laparoscopic surgeons, it remains the gold standard for hernia repairs indisputably.

[Preparation and operative technique for giant inguino-scrotal hernia]. / Extrém nagy inguinoscrotalis sérv elôkészítése és mûtéti megoldása.

The authors present their experience during a successful operation of an inguino-scrotal giant hernia. The enormous hernia had been enlarging for 8 years. First, the abdominal wall was gradually expanded by creating a pneumoperitoneum. Then the abdominal circumference was increased by 16 cm using a polypropylene mesh implanted in a sub-lay position in the midline - thus enabling the repositioning of the exteriorated hernia content into the abdomen.

Primary pulmonary choriocarcinoma: a case report.

BACKGROUND: Primary pulmonary choriocarcinoma (PPC) is an extremely rare clinical entity. In contrast with gestational trophoblastic tumors that show an extreme sensitivity for chemotherapy, extragonadal choriocarcinomas are mostly unresponsive to surgical and chemotherapeutic treatment and are associated with poor prognosis. The reason non-gestational choriocarcinomas behave so differently from gestational tumors is unknown. CASE: In the present case we report a 30-year-old female patient with primary choriocarcinoma of lung localization who was successfully treated with surgical resection and multiple cycles of combination chemotherapy. During her recovery she was followed up by human chorionic gonadotropin (hCG) titer measurement, and after 1 year of close surveillance of beta-hCG levels her disease achieved complete remission. CONCLUSION: Because of the extreme rarity of this malignancy, there are no standardized therapeutic guidelines for treatment. The first choice in treatment of PPC is surgical resection. Postoperatively chemotherapy is indicated immediately, because definitive histologic diagnosis is not essential before chemotherapy since beta-hCG is a reliable tumor marker for choriocarcinoma.

25 years' experience in the treatment of gestational trophoblastic neoplasia in Hungary.

OBJECTIVE: To review our clinical experience in the treatment of gestational trophoblastic neoplasia (GTN) over the past 25 years in our national trophoblastic disease center. STUDY DESIGN: Between January 1, 1977, and December 31, 2001, we treated 355 patients with GTN. The patients were between 14 and 53 years of age, with an average of 28.3. Primary chemotherapy was selected based on the patient's stage of gestational trophoblastic tumor (GTT) and prognostic score. RESULTS: We found metastases in 49.3% (175 of 355) of our patients. Of 173 patients, 162 (93.2%) achieved remission as a result of methotrexate therapy. In 11 patients (6.8%) complete remission was achieved by combination chemotherapy, in some cases assisted by operation. Of 68 patients, 63 (92.6%) achieved remission as a result of actinomycin D therapy, and 5 (7.4%) achieved complete remission by combination chemotherapy. Chemotherapy, surgical intervention or other supplementary treatments resulted in 100% successful therapy in cases of nonmetastatic and low-risk metastatic disease. CONCLUSION: According to our experience, methotrexate/folinic acid or actinomycin D should be the primary treatment in patients with nonmetastatic or low-risk metastatic GTN. Patients with resistance to single-agent chemotherapy regularly achieve remission with combination chemotherapy.

Our experiences with saphenoperitoneal shunts in the treatment of intractable ascites.

Because of significant expenses and complication rates of traditional pumps (LeVeen, Denver, Agishi) used in the surgical treatment of refractory ascites a simple and cheap operative method has to be found. In saphenoperitoneal shunts the one-way flow is maintained by biologically given double saphenous valves. In our department 11 saphenoperitoneal shunts have been performed on 9 patients (2 female, 7 male) in the past one and a half years. Their ascites have been associated with cirrhosis of the liver (secondary to aethylism in 8, to HBV infection in 1). During the follow-up period significant reduction in body weight and abdominal girth, and increase in diuresis with standard diuretics were seen in 6 patients. The minor complications (3 seromas, 3 hematomas, 2 cellulitis) have been self-limiting in general. In the presence of major complications (1 peritoneal reflux, 1 severe hypoproteinaemia, 3 shunt occlusion) interventions were needed several times. In one of the occlusions contralateral fistula was created with PTFE prosthesis implantation, in another case desobliteration happened with a silicone drain left in the shunt. The saphenoperitoneal shunts could improve quality of life significantly in successful instances with minimal negative operative effects without the adverse effects of insertion of foreign material.

[Intravenous immunoglobulin treatment of recurrent spontaneous abortion with immunopathological background]. / Az immunpatológiai hátteru habituális vetélés kezelése terhesség alatti intravénás immunglobulinnal.

INTRODUCTION: Recurrent spontaneous abortion (RSA) is diagnosed if three or more spontaneous abortions follow each other typically in the first trimester. The root cause of miscarriages often can not be found. A significant proportion of this unexplained RSA cases may be caused by immunopathological failure. AIM: A multicentric clinical study started in 2000 to introduce an immunological screening protocol for patients suffering in idiopathic habitual abortion, and to use immunotherapy for their treatment if immunological background was defined. METHOD: The general checkup of the patients was managed based upon a detailed protocol, with which non-immunopathological reasons for RSA were excluded. The unexplained RSA cases underwent an immunological checkup including cellular and humoral immunological, immunogenetic and autoimmune examinations. Based upon these parameters, the immunopathological background of RSA was certified or excluded. In the confirmed immunopathological cases intravenous immunoglobulin (IVIG) therapy was applied during their next pregnancy, with continuous monitoring of the immunological parameters. RESULTS: 120 patients with RSA were examined, and 32 of them got IVIG therapy during their next pregnancy. In 72% of cases (23/32) IVIG treatment for RSA with immunopathological alloimmune background was successful, with the outcome of healthy newborn. Of the 9 unsuccessful cases, in 6 patients subsequently additional non-immunopathological reasons were diagnosed for their RSA. IVIG treatment of patients with clear alloimmune background was successful in 88.5% (23/26). CONCLUSION: Results show that immunopathological checkup and immunotherapy is a useful treatment in the modern medicine for the patients with unexplained RSA. However the success of this method depends on the adherence of the checkup protocol, because unsuccessful therapy of non-clear cases can reduce the efficiency.

[The treatment of inguinofemoral hernias with laparoscopic herniorraphy. Our experience of 1210 transabdominal preperitoneal (TAPP) reconstructions]. / A lágyéktáji sérvek gyógyítása laparoszkópos hernioplasticával: 1210 transabdominalis praeperitonealis (TAPP) muitét tapasztalata.

In 11 years (1994-2005) our team has carried out 1210 transabdominal preperitoneal herniorrhaphies in 964 patients. We operated monolateral hernias in 602 (62.4%) patients, bilateral hernias in 246 (25.5%), among these occult contralateral hernias in 96 (10%), femoral hernias 20 (2%). 28% (N=269) of all operations were performed on because of recurrent hernias. In 6 selected patients incarcerated hernias were operated on by surgeons with sufficient experience. In 16 patients with concomitant abdominal disease we performed synchronous laparoscopic operations (15 cholecystectomies, 1 Meckel diverticulum resection). The average operation time was 112 minutes (52-195), in monolateral hernias during the learning curve, this was reduced to 57 minutes (40-125). The only conversion (0.08%) was necessary because of bowel injury, two early reoperations (0.16%) happened because of bowel perforation caused by electrocoagulation (laparotomy) and because of clipped nervus cutaneus femoris (clip laparoscopically removed). Sero-haematoma (86 = 7.1%) which is the most common mild complication did not occur after the introduction of routine pre-peritoneal drainage. Hydrocele, which developed in the remnant of the sac was operated on in 3 (0.25%) patients. This complication develops when the hernia sac could not be lifted laparoscopically into the abdominal cavity. This complication was eliminated when we removed the scrotal sac through a small skin incision at the end of the operation. Mean hospital stay was 3 (2-7) days, the mean return to normal activity 7-10 days. The majority (N=9) of 11 (0.9%) recurrences occurred in the learning curve. Our experience which is similar to what can be found in numerous other articles showed, that LH is beneficial (short hospitalisation, early return to normal activity, more favourable operability in bilateral and recurrent hernias, early recognition of contralateral occult hernias, performance of synchronous laparoscopic operations, small recurrence rate, improved surgical training) so it should be rightly considered as the gold standard of inguinal hernioplasties.

Human chorionic gonadotropin follow-up in patients with molar pregnancy: a time for reevaluation.

OBJECTIVE: To determine how often patients with molar pregnancy do not complete recommended follow-up and to identify factors that may predict failure to complete human chorionic gonadotropin (hCG) monitoring. This study also sought to determine how often patients with molar pregnancy who do not complete follow-up relapse after attaining at least one undetectable hCG value. METHODS: Four hundred randomly selected patients with molar pregnancy were analyzed regarding the serum hCG levels after molar evacuation. Demographic factors were determined for each patient: age, marital status, gravidity, parity, health insurance type, and distance from patient residence to trophoblastic center. RESULTS: Recommended hCG follow-up was completed in 63% of the uncomplicated 333 cases (n = 211). Three hundred twenty patients achieved at least one undetectable serum hCG level. Among the 320 patients, 33% achieved undetectable hCG values but did not complete recommended follow-up. However, none had any evidence of relapse. A distance of greater than 20 miles from the patient's residence to our center was associated with failure to complete hCG follow-up (P =.001). CONCLUSION: Because none of the 320 patients who achieved at least one undetectable hCG level has been diagnosed with gestational trophoblastic tumor relapse, it may be appropriate to reassess the duration of hCG monitoring for patients with molar pregnancy.

How long should patients be followed after molar pregnancy? Analysis of serum hCG follow-up data.

OBJECTIVE: We analyzed human chorionic gonadotropin (hCG) follow-up data of patients with molar pregnancy. Women often do not complete recommended post-disease screening. Our purpose was to determine if continuing follow up of uncomplicated molar cases beyond attaining undetectable hCG levels is necessary for detecting relapse of gestational trophoblastic disease. STUDY DESIGN: One hundred fifty patients treated at Hungarian National Health Center were analyzed. Those who developed persistent disease before hCG had become undetectable were excluded from further analysis (n=24; 16%). RESULTS: Among 126 uncomplicated cases, 72 patients (57%) completed follow up, and 54 (43%) discontinued their protocol before it had been completed. Of 120 patients who achieved at least one undetectable hCG level, none had any evidence of relapse. CONCLUSION: In uncomplicated hydatidiform mole, our analysis indicates that once undetectable serum hCG levels are attained, relapse is unlikely. Although further monthly checks are advisable, the likelihood of recurrence appears very low.

[Experience with saphenous-peritoneal shunts in the treatment of intractable ascites]. / Saphenoperitonealis shunt képzésével szerzett tapasztalataink a refrakter ascites kezelésében.

INTRODUCTION: The price and complication rates of pump models applied in the treatment of intractable ascites are significantly high. The development of a more simple, cheaper technique--using the biologically given venous valves--the saphenoperitoneal shunts became essential. TECHNIQUE AND RESULTS: In authors' department 11 saphenoperitoneal shunts have been performed on 9 patients from 01.01.2001. to 01.04.2002. After operation significant reduction in abdominal girth and increase in diuresis with diuretics in unchanged doses were observed in 6 patients decreasing their dyscomfort. In one of the patients the ligation of fistula have been needed due to peritoneal reflux, in another one severe hypoproteinaemia have developed. In 3 cases shunt occlusions have appeared: one of them have got Denver-shunt, in other case contralateral saphenoperitoneal shunt have been created with PTFE prosthesis implantation, in the third patient desobliteration have been performed with silicone drain. CONCLUSIONS: Significant improvement of quality of life would be caused by saphenoperitoneal shunts with minimal negative operative effects in successful cases. Besides this method is cost-effective, and has moderate and well corrigable hemodynamic effects.

[Laparoscopic treatment of bile leakage from the Luschka duct after laparoscopic cholecystectomy]. / Luschka-járati epecsorgás laparoszkópos ellátása laparoszkópos cholecystectomia után.

The possible reasons for bile leakage following laparoscopic cholecystectomy are the injury of the common bile duct, the insufficient treatment of cystic duct (non competent or non closing, or spontaneously removing clip, stumpnecrosis due to electrocoagulation near to clipp, rupture adjacent to the clipp) or the opening of an aberrant bile duct. The latter often may occur in case of the anatomic variation described by Hubert von Luschka (1820-1875) a German anatomist as the duct named after Luschka. In a favorable case the accessory bile duct closes by itself, but occasionally developing biloma and/or biliary peritonitis need to be operated on. The authors write about the case of a 52 years old female patient, who underwent laparoscopic cholecystectomy, and 3 days later the complication was averted through the application of relaparoscopy with intracorporal suture. In connection with this case the authors acquaint the readers with the biography, the academic carrier of Hubert von Luschka, and the literature related to Luschka duct is surveyed.

[Cryosurgery and endoscopy in the treatment of varicose veins]. / Kryo és endoszkópia a visszérsebészetben.

Multiplex wide incisions and often deforming scars following varicose surgery are out of date. Nowadays cryoprobes are used to remove epifascial varicose veins, while endoscopy is used to treat transfascial (perforating) venous insufficiency. We analyse the results of 1000 cryovaricectomies performed in the last 8 years. Complications developed in 5.8%, mostly were self-limiting. It is a fast operation, offering good aesthetic result, and hospital stay is short. Subfascial endoscopic perforating veins surgery (SEPS) have been carried out in 2 years in 28 patients, 8 had active ulcers, combined operation have been performed in 20 patients. There were 3 wound complications, which was a very good result compared with high complication rate of earlier used open divisions. The biggest advantage of the procedure is, that it can be performed even if the ulcer is active, since the operation is performed on intact area. Both methods meet the requirements of minimal invasive surgery, with excellent cosmetic and functional results.